In our continuing assessment of Uganda's performance on the Millennium Development Goals, RICHARD M. KAVUMA reports that hundreds of Ugandan children still die every day of illnesses that could be easily prevented

Mary Gorette Nakalyango, 23, ran the blue comb through her hair and patted it, looking in the small mirror with quiet excitement, like a teenager expecting her suitor.

On the bare hospital mattress before her, her second child, 3-month-old Allen Namukwaya, grinned as she grabbed at some invisible objects. Outside this paediatric ward at Biikira Hospital in Rakai district, a boda boda motorcycle waited to take mother and child back home.
Nakalyango’s excitement was borne out of relief.

ESCAPE: This baby from Iganga got malaria in her second week but recovered. Hundreds other Ugandan babies die each day

Four days earlier, she had arrived here anxious, with baby Allen hardly able to breathe or keep her eyes open. But after two units of blood and water, the baby had now been discharged.

“I was so scared. I feared my child would die. No mother wants to produce children for death to grab,” said Nakalyango, by now cuddling her baby as the impatient boda boda man revved his engine.
She had reason to be relieved. In Uganda, for every 1,000 babies born, 88 die within one year (infant mortality), while 152 die before making five (child mortality). And every year, malaria kills 70,000 Ugandan children.

Baby Allen could easily have been one of them.
In 1990, Uganda’s child mortality rate stood at 167 for every 1,000 live births. In the last 15 years, it has only fallen to 152 per 1,000 whereas the internationally agreed Millennium Development Goal (MDG) 4 aims to reduce it to 57 over the next 10 years.

Clearly, this is an ambitious target, a point that government concedes.
According to the Ministry of Finance, Planning and Economic Development, child mortality is influenced by factors such as education, safe water, basic healthcare and security. In a July 2005 progress report on the MDGs, the ministry says infant and child mortality have stagnated since the 1970s.

Government missed its own targets of reducing infant deaths to at least 78 per 1,000 live births by 2002 and 68 by 2005. Uganda is therefore unlikely to meet the MDG target of reducing infant mortality to 31 per 1,000 births by 2015.
Under-5 mortality rates have not done any better: “In view of the current performance, it is hard to be optimistic about the attainment of both the 2005 PEAP target [103] and the 2015 MDG [57],” the report says.

Why do the children die?

According to Dr. Chris Baryomunsi, a programme officer with the United Nations Population Fund (UNFPA) in Kampala [He has since become Kinkizi East MP - Ed], most of Uganda’s children die of preventable diseases such as malaria, diarrhoea as well as HIV/AIDS-related illnesses.

The government’s Poverty Eradication Action Plan (PEAP) document says the level of education and sensitisation is important. Studies show that mothers who are educated or have specific information about the causes of illness prevent and manage diseases better.
Assistant Commissioner for Child Health, Dr. Charles Mugero, also blames child deaths on “underlying environmental factors” such as poverty, hygiene and sanitation conditions, as well as limited safe water supply at household level.

Dr. Jotham Musinguzi, director of the Population Secretariat, says that to save children, emphasis must also be put on maternal health because most infants die soon after delivery.
“Things to do with delivery and safe motherhood become very important for the protection of infants,” he said. MDG5 aims to improve maternal health.

“The other cause is immunisable diseases on which the Ministry of Health has done very well, with coverage of over 84% from less than 50% barely eight years ago,” Musinguzi added.
While the death of children from preventable diseases is a huge indictment on the country, it is also an opportunity: these children can be saved.

Malaria alone, which could easily have claimed Nakalyango’s baby, is said to kill around 70,000 children every year.
“The real problem that we have now is malaria and we need to tackle it,” says Musinguzi. “And the easy way to tackle it is universal use of insecticide-treated nets. Most of the time, the mosquitoes bite the people at night when they are sleeping. I sleep under a bed net and I have not had malaria for the last seven years.”
Musinguzi argues that for nets to be effective, they should not just be for children and women but all Ugandans.

But as Dr. Baryomunsi noted, such interventions can be frustrated by local attitudes. There are longstanding fears, for instance, that immunisation is dangerous to children. One time, a radio station actively campaigned against the programme. Similarly, many people claim that insecticide-treated nets must be harmful to people.
“If a mosquito can land on the net and it dies, why do you think a person can sleep under it for the whole night, inhaling that substance, and they are not affected?” asked a middle-aged university graduate in Kampala.

Poverty too is a hindrance. Mid last year, The Daily Monitor reported that poor brides in Tororo were making bridal dresses out of mosquito nets provided free by an NGO. In a district where only 10 percent of households use mosquito nets, the case demonstrates just how difficult it is to wage an effective campaign against malaria.

Another intervention being considered is the use of DDT residual spray against mosquitoes. Although highly regarded, DDT is opposed by environmentalists and, lately, exporters. These insist that it would be harmful both to human beings and to business with the European Union which imports our fish and flowers.

“Of course we should also study the possible use of DDT while we protect our exports,” says Dr. Musinguzi. “DDT is very effective but we need to make sure we use it for public health and it does not get into agriculture.”

Basic interventions

According to Dr. Mugero, the government is addressing child mortality through four key initiatives: Nutrition, Integrated Management of Childhood Illnesses (IMCI), Control of Diarrhoeal Diseases and School Health.

IMCI, developed by WHO, USAID and UNICEF, involves comprehensive diagnosis and treatment of sick children, including advice on nutrition. One strategy against malaria, the leading killer, is home-based management and treatment of the disease. Selected people in villages distribute malaria drugs (Homapak) for use within 24 hours of recognising malaria symptoms.

But as Baryomunsi and Musinguzi noted, for these measures to make an observable impact, they must be made available in each village. For instance, Nakalyango had never heard of Homapak and her first response was the hospital, which came after 36 hours of fearing that her child was sick.

Assistant Commissioner Mugero also raises another challenge for the Homapak, containing sulfadoxine-pyrimethamine (Fansidar) and Chloroquine. With the drug policy adopting Artemisinin as the first-line of treatment for malaria, the Homapak now needs to be repackaged. Not only does Artemisinin cost over 10 times more than Fansidar and Chloroquine, its supply is still limited.

According to the PEAP document, Uganda could learn from countries like Cuba, China and Sri Lanka that were able to improve child health without large budgets.

“The lessons suggested by these countries include the enormous importance of getting simple health messages out to the population, and the importance of community-level management using very cheap personnel sometimes known as barefoot doctors,” the document says.
Uganda’s children also feed very poorly and suffer an acute lack of vitamin A. Despite the fertile soils and the fact that we grow lots of food, Baryomunsi says, malnutrition is behind 60 percent of the causes of child-deaths.

The Uganda NGO Forum suggests in its May 2005 report on MDGs that the government should prioritise this indicator and provide children with vitamin A-fortified foods.

An underlying cause of the poor child health was, ironically, the introduction of decentralisation in the mid 1990s. Some districts lacked capacity to undertake programmes like immunisation.

According to Dr. Chris Baryomunsi, many local governments seem to be more concerned with politicking than development issues.
“Government must initiate and lead a campaign to ensure that local leaders focus on issues like child health and maternal health, which impact directly on the lives of the people,” he said.

Perhaps recognising that gap, Mugero, the assistant commissioner for child heath, highlights the need to “strengthen district and community participation in child survival interventions.”

As a relieved Nakalyango left hospital with her baby, she couldn’t have agreed more: “Government should help us with mosquito nets. For me, I want the net but I haven’t got the money.”

rimkav@ugandaobserver.com

Only in The Weekly Observer Next Thursday: How many more mothers must die before decisive action is taken